Estimation of the Added Cancer Risk Derived From EVAR and CTA Follow-Up.

OBJECTIVE: The aim of this study was to assess the risk of radiation-induced cancer development in patients that have undergone an infrarenal EVAR, stratifying the relative contributions of the procedure and the preoperative and postoperative CTAs. METHODS AND MATERIALS: The organ-specific absorbed radiation doses from CTA and the EVAR procedure were estimated from the radiation exposures of 95 and 45 male patients, respectively. Lifetime attributable risk (LAR) cancer predictions were calculated for 14 different organs. Life expectancy was assumed from a previous cohort of patients undergoing infra-renal EVAR. RESULTS: The calculated total excess cancer risk was 0.0046, ie, 1 out of 220 patients will develop a neoplasm after being exposed to the ionizing radiation from the preoperative CTA, the EVAR and annual CTA examinations for 15 years. The procedure and the preoperative CTA contributed with 38% of the total excess risk, while the rest was derived from the follow-up. If the entire CTA based follow-up would have been eliminated, an excess risk of 0.0018 (1/560) would remain. CONCLUSIONS: 1 out of 219 patients who have undergone EVAR of an infra-renal AAA have a lifetime risk of developing cancer secondary to the radiation exposures related to the procedure and the CTAs used preoperatively and during follow-up. This risk derives mostly from the yearly postoperative CTAs, underlining the potential benefits of reducing or replacing their use. CLINICAL IMPACT: A simulation-based estimation reinforced the potential deleterious effects of the radiation exposure for patients undergoing Endovascular Aneurysm Repair (EVAR) of Abdominal Aortic Aneurysms (AAA) and subsequently followed by yearly Computer Tomography Angiographies (CTAs). The risk could be as high as 1 out 219 patients developing a neoplasm after 15 years. The largest exposure derives from the follow-up CTAs and efforts to minimize their use as well as the intraoperative radiation are greatly needed. The simulation-based estimations done in this study reinforce potential deleterious effects of the radiation exposure for patients undergoing EVAR of AAA. Efforts should be done to minimize the intraoperative radiation and the number of CTAs used during follow-up.

Low-dose radiation with 80-kVp computed tomography to diagnose pulmonary embolism: a feasibility study.

BACKGROUND: Mounting collective radiation doses from computed tomography (CT) implies an increased risk of radiation-induced cancer in exposed populations, especially in the young. PURPOSE: To evaluate radiation dose and image quality at 80-kVp CT to diagnose acute pulmonary embolism (PE) compared with a previous study at 100 and 120 kVp with all other scanning parameters unchanged. MATERIAL AND METHODS: A custom-made chest phantom with a 12 mg I/mL-syringe was scanned at 80/100/120 kVp to evaluate relative changes in computed tomographic dose index (CTDI(vol)), attenuation, image noise, and contrast-to-noise ratio (CNR). Fifty patients underwent 80 kVp 16-row detector CT at 100 "Quality reference" mAs. A total of 350 mg I/kg were injected to compensate for increased CNR at 80 kVp, while 300 mg I/kg had been used at 100/120 kVp. CTDI(vol), dose-length product (DLP), and estimated effective dose were evaluated including Monte Carlo simulations. Pulmonary artery attenuation and noise were measured and CNR calculated. Two radiologists evaluated subjective image quality using a four-grade scale. RESULTS: Switching from 120 to 80 kVp in the phantom study decreased radiation dose by 67% while attenuation and noise increased 1.6 and 2.0 times, respectively, and CNR decreased by 16%. Switching from 120 to 80 kVp in the patient studies decreased estimated effective dose from 4.0 to 1.2 mSv (70% decrease) in median while pulmonary artery attenuation and noise roughly doubled from 332 to 653 HU and from 22 to 49 HU, respectively, resulting in similar CNR (13 vs. 12). At 80 kVp all examinations were regarded as adequate (8%) or excellent (92%). CONCLUSION: Switching from 120 to 80 kVp CT without increased mAs but slightly increased iodine dose may be of special benefit to diagnose PE in younger individuals with preserved renal function where the primary aim is to minimize radiation dose and reaching levels below that of scintigraphy.

Optimization of radiation exposure and image quality of the cone-beam O-arm intraoperative imaging system in spinal surgery.

STUDY DESIGN: Retrospective study. OBJECTIVES: To optimize the radiation doses and image quality for the cone-beam O-arm surgical imaging system in spinal surgery. SUMMARY OF BACKGROUND: Neurovascular compromise has been reported after screw misplacement during thoracic pedicle screw insertion. The use of O-arm with or without navigation system during spinal surgery has been shown to lower the rate of screw misplacement. The main drawback of such imaging surgical systems is the high radiation exposure. METHODS: Chest phantom and cadaveric pig spine were examined on the O-arm with different scan settings: 2 were recommended by the O-arm manufacturer (120 kV/320 mAs, and 120 kV/128 mAs), and 3 low-dose settings (80 kV/80 mAs, 80 kV/40 mAs, and 60 kV/40 mAs). The radiation doses were estimated by Monte Carlo calculations. Objective evaluation of image quality included interobserver agreement in the measurement of pedicular width in chest phantom and assessment of screw placement in cadaveric pig spine. RESULTS: The effective dose/cm for 120 kV/320 mAs scan was 13, 26, and 69 times higher than those delivered with 80 kV/80 mAs, 80 kV/40 mAs, and 60 kV/40 mAs scans, respectively. Images with 60 kV/40 mAs were unreliable. Images with 80 kV/80 mAs were considered reliable with good interobserver agreement when measuring the pedicular width (random error 0.38 mm and intraclass correlation coefficient 0.979) and almost perfect agreement when evaluating the screw placement (κ value 0.86). CONCLUSIONS: The radiation doses of the O-arm system can be reduced 5 to 13 times without negative impact on image quality with regard to information required for spinal surgery.

Automatic exposure control in computed tomography--an evaluation of systems from different manufacturers.

BACKGROUND: Today, practically all computed tomography (CT) systems are delivered with automatic exposure control (AEC) systems operating with tube current modulation in three dimensions. Each of these systems has different specifications and operates somewhat differently. PURPOSE: To evaluate AEC systems from four different CT scanner manufacturers: General Electric (GE), Philips, Siemens, and Toshiba, considering their potential for reducing radiation exposure to the patient while maintaining adequate image quality. MATERIAL AND METHODS: The dynamics (adaptation along the longitudinal axis) of tube current modulation of each AEC system were investigated by scanning an anthropomorphic chest phantom using both 16- and 64-slice CT scanners from each manufacturer with the AEC systems activated and inactivated. The radiation dose was estimated using the parameters in the DICOM image information and image quality was evaluated based on image noise (standard deviation of CT numbers) calculated in 0.5 cm(2) circular regions of interest situated throughout the spine region of the chest phantom. RESULTS: We found that tube current modulation dynamics were similar among the different AEC systems, especially between GE and Toshiba systems and between Philips and Siemens systems. Furthermore, the magnitude of the reduction in the exposure dose was considerable, in the range of 35-60%. However, in general the image noise increased when the AEC systems were used, especially in regions where the tube current was greatly decreased, such as the lung region. However, the variation in image noise among images obtained along the scanning direction was lower when using the AEC systems compared with fixed mAs. CONCLUSION: The AEC systems available in modern CT scanners can contribute to a significant reduction in radiation exposure to the patient and the image noise becomes more uniform within any given scan.

Low-dose helical computed tomography (CT) in the perioperative workup of adolescent idiopathic scoliosis.

The study aims were to estimate the radiation dose in patients examined with low dose spine CT and to compare it with that received by patients undergoing standard CT for trauma of the same region, as well as to evaluate the impact of dose reduction on image quality. Radiation doses in 113 consecutive low dose spine CTs were compared with those in 127 CTs for trauma. The inter- and intraobserver agreement in measurements of pedicular width, and vertebral rotation, measurements of signal-to-noise ratio and assessment of hardware status were the indicators in the evaluation of image quality. The effective dose of the low dose spine CT (0.37 mSv) was 20 times lower than that of a standard CT for trauma (13.09 mSv). This dose reduction conveyed no impact on image quality. This low dose spine CT protocol allows detailed evaluation that is necessary for preoperative planning and postoperative evaluation.

Construction and evaluation of a real-time personal dosemeter based on a Si sensor for eye-dose measurement.

The objective was to design a thin, flex card based personal dosemeter with low angular and energy dependence. It is based on silicon diodes that can measure the personal dose equivalent. Anisotropic conducting adhesive was used to connect the Si sensor to the flex card. Its intended use is for interventional radiology and after nuclear or radiological accidents, as it provides immediate detailed information about the dose rate to the wearer during shorter periods and integrates the dose rate during hours. It can be freely placed all over the body. By placing the dosemeter close to the eyes, it may be possible to estimate the personal dose equivalent as well as the dose at the lens of the eye.

Long-term biokinetics and radiation exposure of patients undergoing 14C-glycocholic acid and 14C-xylose breath tests.

The (14)C-glycocholic acid and (14)C-xylose breath tests are clinically used for the diagnosis of intestinal diseases, such as bacterial overgrowth in the small intestine. The two tests have in earlier studies been thoroughly evaluated regarding their clinical value, but due to the long physical half-life of (14)C and the limited biokinetic and dosimetric data, which are available for humans, several hospitals have been restrictive in their use. The aim of this study was to investigate the long-term biokinetics and dosimetry of the two (14)C compounds in patients and volunteers, using the highly sensitive accelerator mass spectrometry (AMS) technique. Eighteen (18) subjects were included, 9 for each compound. The (14)C content in samples from exhaled air, urine, and, for some subjects, also feces were analyzed with both liquid scintillation counting (LSC) and AMS. The results from the glycocholic acid study showed that, up to 1 year after the administration, 67%+/-6% (mean+/-standard deviation) of the administered activity was recovered in exhaled air, 2.4%+/-0.4% was found in urine, and 7.6% (1 subject) in feces. In the xylose study, the major part was found in the urine (66%+/-2%). A significant part was exhaled (28%+/-5%), and the result from an initial 72-hour stool collection from 2 of the subjects showed that the excretion by feces was insignificant. The absorbed dose to various organs and tissues and the effective dose were calculated by using biokinetic models, based on a combination of experimental data from the present study and from earlier reports. In the glycocholic acid study, the highest absorbed dose was received by the colon (1.2 mGy/MBq). In the xylose study, the adipose tissue received 0.8 mGy/MBq. The effective dose was estimated to 0.5 (glycocholic acid) and 0.07 mSv/MBq (xylose). Thus, from a radiation protection point of view, we see no need for restrictions in using the two (14)C-labeled radiopharmaceuticals on adults with the activities normally administered (0.07-0.4 MBq).

CAN AN ENERGY-COMPENSATED SOLID-STATE X-RAY DETECTOR BE USED FOR RADIATION PROTECTION APPLICATIONS AT HIGHER PHOTON ENERGIES?

The objective of this study was to investigate the characteristics of a solid-state detector commonly available at hospitals for parallel use as a real-time personal radiation monitor following radiation emergency situations. A solid-state detector probe with an inherent filtration (R100, RTI Electronics AB, Mölndal, Sweden) was chosen for evaluation. The energy dependence and the linearity in signal response with kerma in air were examined, and the detector was exposed to both X-ray beams using a conventional X-ray unit with effective photon energies ranging between 28.5 and 48.9 keV and to gamma rays 1.17 and 1.33 MeV from (60)Co. The R100 exhibited ∼1.7 times over-response at the lowest X-ray energy relative to the (60)Co source. The detector demonstrated a linear response (R(2) = 1) when irradiated with (60)Co to air kerma values in the range of 20-200 mGy. The conclusion is that high-energy photons such as those from (60)Co can be detected by the R100 with an energy response within a factor of <2 over the energy range examined and that the detector can provide real-time dose measurements following nuclear or radiological events.

Biokinetics and radiation dosimetry for patients undergoing a glycerol tri[1-14C]oleate fat malabsorption breath test.

The glycerol tri[1-14C]olein test for fat malabsorption was carried out in two male volunteers and measurements of the loss of 14C in expired air, urine and faeces and the retention of 14C in biopsy samples of abdominal fat were made using accelerator mass spectrometry. Exhalation accounted for 73% and 55% of the administered activity and could be described by three-component exponential functions with halftimes of about 1h, 2 days and 150 days, respectively. Urinary excretion accounted for 24% of the administered activity, almost all during the first 24h after administration; about 2% was excreted in the faeces in 48h. The halftime of retention of 14C in fat ranged from 137 to 620 days. Absorbed dose calculations indicate that for a normal adult the largest dose, 1.5-7.0mGy/MBq is received by the adipose tissue, and that the effective dose is 0.3-0.5mSv/MBq. It is concluded that no restrictions need to be placed on radiation safety grounds on the administration of 0.05-0.1MBq 14C-triolein for the triolein breath test.

The effect of different adaptation strengths on image quality and radiation dose using Siemens Care Dose 4D.

The purpose of this study was to evaluate the effect of different choices of adaptation strengths on image quality and radiation exposure to the patient with Siemens automatic exposure control system called CARE Dose 4D. An anthropomorphic chest phantom was used to simulate the patient and computed tomography scans were performed with a Siemens SOMATOM Sensation 16 and 64. Owing to adaptation strengths, a considerable reduction (26.6-51.5 % and 27.5-49.5 % for Sensation 16 and Sensation 64, respectively) in the radiation dose was found when compared with using a fixed tube current. There was a substantial difference in the image quality (image noise) between the adaptation strengths. Independent of selected adaptation strengths, the level of image noise throughout the chest phantom increased when CARE Dose 4D was used (p < 0.0001). We conclude that the adaptation strengths can be used to obtain user-specified modifications to image quality or radiation exposure to the patient.

Simulated dose reduction by adding artificial noise to measured raw data: a validation study.

The purpose of this study was to verify and validate a noise simulation tool called Dose Tutor (VAMP GmbH) in terms of level and texture of the simulated noise. By adding artificial noise to measured computed tomography (CT) raw data, a scan acquired with a lower dose (mAs) than the actual one can be simulated. A homogeneous polyethylene phantom and an anthropomorphic chest phantom were scanned for different mAs levels, tube voltages, slice thicknesses and reconstruction kernels. The simulated noise levels were compared with the noise levels in real transverse slice images actually acquired with corresponding mAs values. In general, the noise comparisons showed acceptable agreement in magnitude (<20 % deviation in pixel standard deviation). Also, the calculated noise power spectra were similar, which indicates that the noise texture is correctly reproduced. In conclusion, this study establishes that the Dose Tutor might be a useful tool for estimating the dose reduction potential for CT protocols.

Post-processing image filtration enabling dose reduction in standard abdominal CT.

The collective effective radiation dose to the population is increasing due to a higher use of computerised tomography. SharpView AB, Linköping, Sweden, has developed an adaptive non-linear post-processing image filtration that may enable the use of lower radiation doses. The present study assessed if a lower dose with image filtration had the same image quality as a higher dose without the filter applied. All imaging was performed on a Siemens Somatom Sensation 16 CT. The parameters used were 120 kV and 200 mAs (40 patients) and 130 mAs without and with image filtering (40 patients), respectively. All studies were quantitatively evaluated for noise and image quality was assessed by visual grading characteristics (VGC) analysis. After image filtration, the noise in the processed images was lowered and the image quality was improved as shown by the VGC analysis. However, images using the higher dose were still ranked as the best in five out of eight criteria as shown by the VGC analysis. Image filtration enhances CT images significantly and further studies will show if 130 mAs with image filtration may be sufficient for clinically general abdominal CT.